Form 0285 contact infor 0285 contact infor 0285 contact information

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx
DEPARTMENT OF
HEALTH AND HUMAN
SERVICES
Health Resources and
Services Administration

FOR HRSA USE ONLY
Application Tracking Number

Grant Number

CONTACT INFORMATION
Medical Director
Name
Phone
Email
Dental Director
Name
Phone
Email
Contact Person
Name
Phone
Email
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public
reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.